The Deadliest Disorder

Mental illnesses can be life threatening, but which one has the highest mortality rate? Fifty percent of people with schizophrenia attempt suicide. Nearly fifteen percent of those who are clinically depressed take their own life. But neither of these illnesses has the highest mortality rate. The answer, I was surprised to learn in a recent lecture by child and adolescent psychiatrist, Dr. Michelle Jorgensen, is eating disorders. People with eating disorders have a high risk of suicide, but in addition the chronic malnutrition they suffer extracts a physical toll on the body. The combined mental and physical assault boosts the mortality rate from death by sudden heart attack, multiple organ failure, and other deadly consequences of prolonged malnutrition.

"There is nothing wrong with me," is the common reaction Dr. Jorgensen says most of her patients have when a loved one brings them to her for treatment at the Eating Disorders Institute in Fargo, North Dakota. Rarely will a patient seek treatment on their own. People with eating disorders suffer a delusion that they are overweight. Their perception of reality becomes distorted to the extent that their own withered leg, compared side-by-side to a healthy person's muscular leg, will be perceived by the patient as being fat. This is what makes treatment so difficult. Relapse is very common. 50-70% who seek treatment will recover; 20% will improve with treatment but still struggle with the disorder, and 10-20% will die.

Eating disorders ranks among the ten leading causes of disability for young women, but I was surprised to learn that this is not exclusively a female malady. One out of 4 patients with an eating disorder is male. For men, this often results using something other than purging a meal to eliminate calories-exercising to excess.

"People have the perception that an athlete couldn't have an eating disorder," Dr. Jorgensen told me, but in fact many kinds of athletes: runners, jockeys, gymnasts, rock climbers, dancers, track and field athletes, wrestlers, and marathon runners, share with the stereotypic fashion model an idealized body image which they feel is necessary to excel in their career. Many of these individuals are highly motivated, even compulsive about their exercising.

"It is very hard to get people to stop exercising to excess, because you do feel withdrawal when you stop exercising," Dr. Jorgensen explained. She described a recent patient who was a 19 year-old male on the college basketball team. "He had a low white cell count, anemia, low red blood cell count, multiple bone marrow cell lines were suppressed-liver enzymes elevated, poor kidney function; he was dehydrated and hypoglycemic, and yet he could not stop exercising." His very low weight raised such concern from his coach and parents that they compelled him to see a doctor. He denied that he had any problem. I asked her, if she were looking only at his medical records and did not suspect that he had an eating disorder, what would the medical profile suggest? "Infectious hepatitis, or cancer," she said.

A review of his training routine showed that he was running 3-4 hrs a day and eating an unbalanced diet restricted to what he believed to be "healthy foods." He had a heart rate in the 40 beats/min range, but a heart monitor revealed that his heart rate plummeted dangerously to 25 beats/minute at night. He was at high risk of sudden heart attack. "It is an urban myth that a low heart rate is always good for athletes. This is not necessarily so. There are very few athletes with a resting rate in the 40s." The reason for the low heart rate in people with eating disorders is that electrolytes (such as potassium) are out of balance, but more importantly because the heart is a muscle. The skin-and-bones bodies of people with eating disorders are the result of muscle tissue being consumed by the body to sustain itself when there is inadequate calorie consumption in the diet. What is less visible, is that the heart muscle suffers the same wasting as a thigh muscle from chronic malnutrition.

The emphasis on dealing with the significant obesity problem in the United States, where people in general have a sedentary life style and poor diet, has led to fashionable notions about "good foods, vs. bad foods." This dichotomy unfortunately contributes to the pathological thinking of people with eating disorders. To lose weight they may begin altering their diet by eliminating fatty foods, but then progress to a vegetarian diet, and ultimately to a very narrow or peculiar diet that does not provide adequate calories or nutrients. "There are no bad foods," Dr. Jorgensen says. "What is in chocolate chip cookies? Eggs, flower, milk, chocolate chips. There is nothing bad in there. An unhealthy diet is one that is unbalanced."

Many people with eating disorders suffer in secret. They avoid meals with friends and family. They conceal their skinny body under layers of clothes. They may exercise to the exclusion of socialization or persist in exercising after injury. They resort to diet pills, binge eating, purging, and most of them will face this life-threatening disorder alone.

Here are a few questions to ask if you suspect that you or someone you know may have an eating disorder:

1. Do you make yourself sick because you feel full?

2. Do you worry that you have lost control over how much you eat?

3. Have you recently lost more than 14 pounds in three months?

4. Do you believe yourself to be fat when others say you are too thin?

5. Would you say that food dominates your life?

An answer of yes to two of the questions above suggests the strong possibility of an eating disorder. An additional symptom for women is the loss of a menstrual cycle. For men, loss of sexual function frequently accompanies eating disorders. The body, male or female, cannot maintain normal reproductive function in the face of life-threatening starvation. Rational thought, clouded by psychiatric disability to perceive that there is a problem, is of no help. Others, including friends, family, coaches, and doctors, must come to the aid of these people who simply cannot help themselves.

This article is very good, but still perpetrates certain myths. You begin by saying eating disorders have the highest mortality rate. Then you describe "eating disorder" by the symptoms of anorexia nervosa, which is only ONE eating disorder. Binge eaters, bulimics, etc., do not necessarily suffer from the delusion they are overweight, though some do. Some genuinely ARE overweight, while others see their (normal) size accurately. This doesn't mean these disorders take any less of a toll on the body. What complicates things is that a bulimic is more likely to die of a sudden heart issue brought on by extreme behavior (exercise and/or vomiting), and an overeater of obesity related causes. Many bulimics have normal vitals, but can lose enough electrolytes in a single night of bingeing and purging to become comatose. Rarely do these deaths or complications get recorded as eating disorder related.

I bring this up because of my own struggle to get help, as someone who has cycled through anorexia, bulimia, and extreme overeating in turns from the age of 9 to my current age of 54. When I was anorexic, everyone was alarmed, because of my appearance, though I was in overall better health than I am now. I am currently bulimic, but find it very difficult, in mental health settings, to get my treatment needs taken seriously because I am not visibly thin, and because my labs are somewhere near normal. I recently went through a Cognitive Behavioral Therapy program where my serious purging behaviors were considered "quality of life" issues, but if I'd been anorexic, that would have been "life threatening." The two categories receive different prioritization, obviously. I can't tell you how many times I have had to answer the question - even from mental health professionals! - "What do you mean you have an eating disorder? You're not skinny." Or worse, "You're overweight - there's no way you're bulimic." Well, this is what 40+ years of restricting, purging, and bingeing looks like: my metabolism no longer functions effectively. Not all of us have the "skin and bones" bodies you describe.

I have lost 6 bulimic - not anorexic - friends who were in treatment with me in the 5 years since I was hospitalized. Their deaths were without question related to bingeing and purging. I wish the mental health community would realize that a person doesn't have to have bones jutting out and refuse all food to be in serious jeopardy from the deviousness of eating disorder - not just emotionally, but physically, as well.